IT failure delays treatment for eight months.

Argue with doctors if you’re in pain, says survivor

It should have been good luck for Gordon Barnes to fall off a ladder, be rushed to hospital, and for a CT scan to find he had cancerous lymph nodes.

But that luck was snatched away by an outdated computer system that did not alert Wairarapa Hospital doctors to the surprise result, leaving Barnes’ rectal cancer undiagnosed for eight months.

It was eventually discovered after repeated trips to the doctor for ongoing pain.

Barnes, from the Alpaca Place in rural Masterton, is now in remission, but doesn’t want another patient to “fall through the cracks”, as he had.

He has lost all faith in the Wairarapa District Health Board.

“I wouldn’t trust the system with a band-aid,” he said last week.

Barnes, 74, and his wife, Liz, filed a complaint to the Health and Disability Commission in January 2017.

The commission’s report, released this week, found that multiple doctors and nurses had missed the crucial note that Barnes had “numerous enlarged rectal lymph nodes” because of a “weak IT system”.

Barnes urges people who feel unwell to keep pushing until something is found but admitted that can be difficult.

“Don’t take a doctor’s word as final. They are human, they make mistakes.

“I knew something wasn’t right but I would never had guessed it was cancer,” he said.

“I tried more than five times to get someone to listen to me – I had to explode to get the action I got, but I wouldn’t have got it if I didn’t try.”

The investigation into the treatment he received at Wairarapa Hospital concluded the DHB had breached the Code of Health and Disability Services Consumers Rights for failing to provide “reasonable care
and skill”.

The DHB’s chief medical officer Dr Tom Gibson said “we deeply regret” what had happened, and immediate action had been taken to improve the hospital’s processes.

Gibson has personally apologised to the couple.

On March 15, 2016, Barnes, who was 72 at the time, was taken to hospital after falling about 3m off a ladder while cleaning out gutters.

He had broken several ribs and injured his hip, stomach and chest.

An urgent CT scan was ordered, and he was admitted to the surgical ward.

After three days in hospital, Barnes was discharged, and the CT report notes were never read.

The commission’s report said the hospital’s IT system at the time did not allow for electronic sign-off of test results.

“There was no alert system to notify a doctor that a result had arrived, nor was there a doctor-specific list of results to review,” the report said.

This meant a doctor could not search test results “apart from proactively on an individual-patient basis”.

Barnes became a patient at Masterton Medical after being discharged, with all test results referred there.

He believes “Masterton Medical is equally responsible” for missing the medical note.

He had visited the medical centre several times after being discharged from hospital in March, each time with complaining about bowel problems, irritation and weight loss.

He saw multiple doctors, but it was not until October that a doctor read the original note about the lymph nodes.

He underwent emergency surgery days later.

Masterton Medical general manager Robyn Wilson said that while the commission investigated the centre’s procedures and the actions of its doctors, no breach was found.

The centre had changed its policy, and phoned patients to check everything relating to them had been dealt with, the report said.

The Barnes said that while they could not argue the IT system was the fault, there were human errors made. “They were more focused on the injuries from the fall, that’s probably why they must have missed the cancer,” Barnes said.

Masterton Medical told the commission it was not possible for general practice doctors to follow up all results ordered by the hospital’s emergency department.

Gibson said the IT system was being upgraded to a new regional system, and “electronic sign-off is high on the agenda for this complex upgrade”.